Here are questions to prepare for JCAHO

Below are questions asked of ED nurses at Wake Forest University Medical Center in Winston-Salem, NC, to prepare for an unannounced survey by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO):

  1. Question: How are critical lab or radiology values handled? Answer: Nursing documents the critical test results. A read-back of the information is required. The patient’s physician then is called with the results within 15 minutes of the report. The nurse is prepared to take a telephone order to act on the results.
  2. Question: How do you handle an order that was written using an abbreviation identified as dangerous and not appropriate for use? Answer: Medication orders with unacceptable abbreviations are not accepted by our pharmacy. The physician will be called and asked to rewrite the order.
  3. Question: How do you identify your patient when giving medications or doing procedures? Answer: Our policy requires the use of two patient identifiers. On the inpatient units, the identifiers are patient medical record number and patient name. The nurse checks the patient’s armband with the computer information. In outpatient or ancillary areas, patients may not have armbands. In these cases, the patient’s name and birth data and/or picture ID are used.
  4. Questions: What is an acceptable length of time to answer an equipment alarm? Have audible alarms been set loud enough to be heard over a busy unit? Answer: Alarms are responded to immediately, with prioritization given to patients warranting immediate attention and to critical equipment such as ventilators. All alarms are audible to staff.
  5. Question: How are medications with a range of doses handled? Answer: All orders must be written with a specific dose and frequency. Dose ranges are accepted when a dose and frequency are specific to a quantified monitoring parameter, such as sliding scale insulin for a specific blood glucose value.
  6. Questions: How do you report a medication error? Is there any recrimination for reporting an error? Answer: All clinicians are encouraged to report medication errors, which may be done anonymously. The majority of medication errors involve process issues and not human error. There is no recrimination for reporting medication errors.
  7. Questions: How often do you have fire drills? Where’s the nearest fire extinguisher? Where’s the nearest evacuation route? Answer: Fire drills occur once per shift per quarter. Staff should know where all the fire extinguishers are on their unit. There is a posted evacuation route on each unit, and staff need to know it.